The research, led by Gürkan Tarçın of Kocaeli University Medical Faculty together with colleagues from pediatric endocrinology, emergency, and critical care units across ten institutions, examined 139 children treated for diabetic ketoacidosis between June 2021 and August 2023 in five tertiary centers. Rather than imposing a single protocol, the investigators took advantage of natural variation in routine practice: each center managed DKA according to its own established fluid regimen. This real-world design allowed the team to compare three distinct maintenance and deficit fluid protocols as they were actually delivered at the bedside, capturing the consequences of everyday clinical decisions rather than the idealized conditions of a controlled trial.

All three protocols shared a common opening move. Every child received an initial bolus of isotonic saline to restore circulating volume, the universally accepted first step in DKA resuscitation. The protocols then diverged in the composition of the fluids given over the following hours. Protocol 1 used a solution of 0.6 percent sodium chloride containing 3.3 percent dextrose throughout the entire treatment course. Protocol 2 began with 5 percent dextrose in 0.9 percent sodium chloride for the first six hours, then switched to 0.6 percent sodium chloride with 5 percent dextrose. Protocol 3 continued with 5 percent dextrose in 0.9 percent normal saline for the duration of therapy. The critical chemical difference lay in the chloride load: Protocol 1 delivered roughly 100 milliequivalents of chloride per liter, the lowest of the three, while the protocols built on normal saline carried a substantially heavier chloride burden.

The most striking finding emerged among newly diagnosed children presenting with severe acidosis. In this subgroup, the low-chloride Protocol 1 was associated with a shorter treatment duration and lower peak chloride levels compared with Protocols 2 and 3. In other words, children whose fluids spared them the excess chloride came out of the ketoacidotic state faster and avoided one of the well-recognized side effects of aggressive saline-based regimens: hyperchloremia, an abnormally high blood chloride concentration that can itself produce a non-anion-gap metabolic acidosis and muddy the biochemical picture clinicians rely on to judge recovery.

To move beyond simple group comparisons, the researchers performed a multivariable linear regression analysis, a statistical technique that isolates the independent contribution of each factor while holding the others constant. Three variables independently predicted a longer course of treatment: a lower initial blood pH at presentation, reflecting more profound acidosis on arrival; a higher peak chloride level reached during therapy; and new-onset diabetes, meaning the DKA episode was the child’s first manifestation of the disease. The chloride finding is particularly consequential because it is the one variable clinicians can directly control through fluid selection. A lower starting pH is fixed at the moment of arrival, and whether diabetes is newly diagnosed is a matter of history, but the chloride load delivered through the intravenous line is a protocol choice, and this study suggests it matters.

The biology behind the chloride effect is worth unpacking. Normal saline contains a chloride concentration of about 154 milliequivalents per liter, considerably higher than the roughly 100 to 110 milliequivalents per liter found in human plasma. When large volumes of such fluid are infused, the excess chloride overwhelms renal handling and lowers the strong ion difference in the blood, driving a hyperchloremic acidosis that is physiologically distinct from the ketoacidosis being treated. Clinicians tracking bicarbonate and pH during DKA therapy can then face an ambiguous picture: is the persistent acidosis ongoing ketone production, or is it iatrogenic, manufactured by the resuscitation itself? By keeping the maintenance fluid chloride load near physiological levels, the low-chloride protocol appears to have minimized this confounding, allowing the true resolution of ketoacidosis to show through and, per the study’s results, shortening the time needed to reach treatment endpoints.

Equally notable is what all three protocols had in common: dextrose was included in the initial maintenance and deficit fluids from the outset, regardless of the child’s serum glucose concentration. This runs counter to the instinct, still common in some settings, to withhold glucose until blood sugar falls toward the hypoglycemic range. The authors propose that early dextrose administration may have blunted rapid osmotic shifts, the sudden changes in extracellular tonicity that are thought to contribute to the most feared complication of pediatric DKA: cerebral edema, a swelling of the brain that historically carries significant mortality and neurological morbidity. By providing a steady glucose supply alongside insulin therapy from the first hours, the fluid regimens may have smoothed the osmotic transition as the child’s chemistry normalized.

The safety signal here is remarkable in its own right. Across all 139 children and all three treatment protocols, not a single case of cerebral edema was observed. Given that cerebral edema is rare but devastating, occurring in a small fraction of pediatric DKA episodes, an absence of cases in a cohort of this size cannot prove protection, and the study’s retrospective design limits causal inference. Nevertheless, the combination of early dextrose and controlled osmotic shifts offers a plausible physiological account, and the zero-case outcome is consistent with the hypothesis that gentler fluid chemistry, applied early, may contribute to a safer treatment course. The authors themselves frame it cautiously, suggesting that early dextrose may have minimized rapid osmotic shifts and potentially contributed to the absence of cerebral edema across all groups.

The study’s design deserves both credit and scrutiny. Its multicenter scope, spanning five tertiary hospitals and ten institutional affiliations across Türkiye, lends ecological validity that single-center studies often lack, and the ethics approval from the Istanbul University-Cerrahpaşa ethics committee, with written informed consent obtained from participants and guardians, anchors the work in standard research protections. At the same time, the retrospective cohort structure means the investigators depended on chart documentation, and the assignment of children to protocols reflected where they happened to be treated rather than randomization. Centers may differ in ways beyond fluid recipes, including insulin dosing practices, monitoring frequency, and patient demographics, and although multivariable regression adjusted for key predictors such as initial pH and diabetes status, unmeasured confounding cannot be excluded. A randomized controlled trial would be needed to confirm that the low-chloride, early-dextrose approach itself, rather than the environment in which it was used, drives the faster recovery.

Even with those caveats, the findings arrive at a practical moment. Pediatric DKA remains one of the most common pediatric endocrine emergencies, and international guidance, including that of the International Society for Pediatric and Adolescent Diabetes, continues to evolve on fluid composition. The message emerging from this cohort is twofold. First, the chloride content of maintenance and deficit fluids is not a trivial detail: a regimen delivering roughly 100 milliequivalents per liter was linked to quicker acidosis resolution and less treatment-related hyperchloremia in the sickest children. Second, adding dextrose early, rather than waiting for glucose to fall, appears compatible with, and possibly protective against, the osmotic turbulence that complicates therapy. For emergency physicians and pediatric intensivists, the study reframes a routine order set as an active therapeutic lever, one that could shorten hospital courses and, perhaps, keep children with diabetic ketoacidosis on the safer side of one of medicine’s most feared complications.

Subject of Research: Intravenous fluid composition in the treatment of pediatric diabetic ketoacidosis

Article Title: Early dextrose and lower-chloride fluids in pediatric diabetic ketoacidosis: a faster and safer approach? – A multicenter cohort study

Article References: Tarçın, G., Özer, E., Küçükali, G. K., Yaşar, A., Çakır, A. D., Karakaş, H., Emeksiz, S., Karacan, C. D., Uçar, A., Kırmızıbekmez, H., Çetinkaya, S., Boyraz, M., Cebeci, S. O., Turan, H., Bayramoğlu, E., Aygün, F., & Evliyaoğlu, O. (2026). Early dextrose and lower-chloride fluids in pediatric diabetic ketoacidosis: a faster and safer approach? – A multicenter cohort study. BMC Endocrine Disorders. https://doi.org/10.1186/s12902-026-02555-w

Image Credits: AI Generated

DOI: 10.1186/s12902-026-02555-w

Keywords: diabetic ketoacidosis, pediatrics, type 1 diabetes, intravenous fluids, hyperchloremia, dextrose, cerebral edema, acidosis, emergency medicine, fluid therapy, ISPAD, multicenter cohort study